HomeMy WebLinkAboutBuffalo Wild Wings - 12/31/2021FOR BOARD OF HEALTH USE ONQ( CPermil# Issued
FOOD ESTABLISHMENT PERMIT APPLICATION
(Application must be submitted at least 30 days before the planned openi date)
Establishment Name W 11� "n�S
Establishment Address
mlv)heCkAod\(s. MN " U
Establishment Telephone No 1;506 a 3 .{�`
Applicant Name & Title: B' �2_k"
Applicant Address �J C 5 I�'-('� V i
Si Q�j1� 24 Hour Emergency No.:3'�Q�
Applicant Telephone No.:��2. �Q g y
Applicant Email 6\/�JW LAC-E'-m I�/f`���' jYJ\� byy'� • C,dM
Owner Name & Title (If different from applicant)
Owner Address 5 f `w
Owner telephone number
Owner email:
Establishment Owned By:
El An Association
)<A corporation
O An Individual
El A Partnership
El Other legal Entity
If a corporation or partnership, give name, title, and home address of officers or
partner.
Name Title Address
Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title:
Address:32A .��dv\ S�C V}�i l�
Telephone No: rcoe)1 I Lk� 24 Hour Emergency No:
FAX:
E-mail:
AltE-Mail: bjWbce"irlo)Gy1
District Or Regional Supervisor (if applicable)
Name & Title:
Address:
Telephone No:
FAX:
E-mail:
\\-e.2�Y)68 a c93n
24 Hour Emergency No:
Food Establishment Information
WATER SOURCE:-VoWn SEWAGE DISPOSAL: `_MW n
�Mi1
DE P P lic Water Supply No: (If applicable) No. of Food Em loyees:
DA S) R (ie bb fi file �'_. Q t11- 12(7t I°►1) GVl d SCE i A I Cu-n-I
Name of Person(s) In Charge Certified in Food Protection Management:
Name of Person\(s)_In Charge Certified in Allergen Awareness Training
inspecting the premises for evidence of pests t aP �' a
Name of pest control company routinely
If there is seating for 25 people or more, a person trained in manual choke saving procedures will be onsite at all times
food is being prepared. Yes
Does this establishment require a FOG permit? If yes, please attach the FOG permit application.
Length of Permit:
Establishment Type:
�, Annual
[1 Retail Food $125.00 Mobile Food Consession
[I Temporary
�71 Food Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00
FOOD TRUCKS $175.00 a Manufacture Frozen Desserts/Ice Cream
Temporary Start Date:
Food Service up to 101 -200 $250.00 $25.00/freezer
Temporary End Date:
ry ood Service up to 201 + $300.00 Pushcart $50.00 # of Pushcarts:
Temporary Time:
Supermarkets $400 Residential Kitchen $100.00
Rain Date:
%Milk & Cream $10.00 l Caterer $35.00
Food Operations: Definitions: PHF- Potentially hazardous food (time/temperature controls required)
Non-PHFs - non -potentially hazardous food(no time/temperature controls required)
(Check all that apply): RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing)
U Sale of Commercially Pre -Packaged Non-PHFs To Order EA Hot PHF Cooked and Cooled or Hot Held
JXPHFCooked
for More Than a Single Meal Service
Sale of Commercially Pre -Packaged PHFs 0 Preparation of PHFs For Hot And
Cold Holding For Single Meal Service B PHF and RTE Foods Prepared For Highly
E] Delivery of Packaged PHFs Susceptible Population Facility
Sale of Raw Animal Foods Intended
0 Reheating of Commercially to be Prepared by Consumer ❑ Use of Process Requiring A Variance
Processed Foods for Service Within 4 Hours and/or HACCP Plan (including bare hand
[I Customer Self -Service contact alternative, time as a public health
of Non PHF and Non- control)
Customer Foods
Perishable Foods Only ❑Ice Manufactured and Packaged for
Retail Sale Q Offers Raw Or Undercooked Food Of
I] Preparation of Non-PHFs
Juice Manufactured and Packaged for Animal Origin
Other Food Operations Retail Sale Vacuum Packaging / Cook Chill
Offers RTE PHF in Bulk Quantities Prepares Food/Single Meals for
(] Retail Sale of Salvage, Out -Of -Date Catered Events or Institutional Food Service
or Reconditioned Food
I, the undersigned, attest to the aguracy of the information provided in this application and affirm that the food
establishment operation will comply with 105 CMR 594.000 and all other applicable law. I have been instructed by the
board of health on how to obtain copies of 10{ C,M ,F90.000 and the federal Food Code,
Signature of Applicant:
Pursuant to MGL Ch.62C, sec. 49A, I certify
and paid state taxes required under law.
Social Security Number or Federal ID:
Signature of Individual or Corporate Name:
the pehaRies of perjury that I, to my best knowledge and belief, have filed all state tax returns
0
Cd
U
w
Q
coQto
='aZ a
0
k
C)
o
Cn
m
00
,
�
o
000
z
c
L6
�
co
4
o
cq
00
o
o
LO
a
00
o
�
Qo
N
��
c
�00
co
co
co414
cc
O
a�
o
Q
co
cq
cq
Ua�
a
Cd
zj �j
M N
'ri O N
U r!1
Fi
O
a
U�
�0
U�
a
0
0
Q
0
W
m
w
o
a
z
TOWN OF MANSFIELD LOCAL BYLAWS
The following bylaws apply to all food establishments permitted by the Mansfield Health Department:
Plastic Waste Reduction; Polystyrene Container Reduction; and Plastic Straw/Stirrer Reduction. A copy
of each bylaw is included. It is the responsibility of the applicant to read and understand all bylaws.
Please indicate by initialing the following statements that the permitted food establishment will adhere
to all applicable bylaws. The applicant and associate corporation are subject to fines associated with
violations.
Plastic Waste Reduction
No retail establishment in the Town of Mansfield shall provide thin-film, single -use plastic check-out
bags to customers.
i"CV I have received a copy of the Plastic Waste Reduction bylaw. I understand my responsibility to
ensure that this bylaw is adhered to at the permitted food establishment. I understand violations of this
bylaw will result in fines.
Polystyrene Container Reduction (effective January 1, 2021)
Food establishments are prohibited from dispensing prepared food and drink in disposable food service
containers made from expanded polystyrene. All food establishments are strongly encouraged to use
reusable food service containers and cutlery, and when possible biodegradable, compostable
alternatives. Compostable materials must meet ASTM (American Society of the International Association
for Testing and Materials) Standards for compostability.
"I I have received a copy of the Polystyrene Container Reduction bylaw. I understand my
responsibility to ensure that this bylaw is adhered to at the permitted food establishment. I understand
violations of this bylaw will result in fines.
Plastic Straw/Stirrer Reduction (effective January 1, 2021)
Plastic beverage straws and plastic stirrers shall not be used or dispensed or sold except upon request in
conjunction with the serving by business establishments or at any town -sponsored event of liquid,
slurry, frozen, semi -frozen, or other forms of beverages to the public for consumption.
41 1 have received a copy of the Plastic Straw/Stirrer Reduction bylaw. I understand my
responsibility to ensure that this bylaw is adhered to at the permitted food establishment. I understand
violations of this bylaw will result -in fines.
� ppp
Applicant Signature Date:
Applicant Name (please print clearly) 1``J[ c i Q_4zz�ez�g-r
TAX CERTIFICATION FORM
I certify under the penalties of perjury that I, to my best knowledge and
belief, have filed all state tax returns and paid all state taxes required
under law.
_A \J1 a wes,ider) 1-
of Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable)
4 H95-110-1
"Social Security No. (Voluntary) or Federal
Identification Number
*This license will not be issued unless this certification clause is signed
by the applicant.
** Your social security number will be furnished to the Massachusetts
Department of Revenue to determine whether you have met tax filing or
tax payment obligations. Licensees who fail to correct their non -filing or
delinquency will be subject to license suspension or revocation. This
request is made under the authority of Massachusetts General Law
Chapter 62C, section 49A.
C:\Users\sleite\Desktop\Scott's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc
Town of Mansfield Health Department
APPLICATION FOR FATS OILS and GREASE DISCHARGE PERMIT
RESTAURANT & FOOD PREPARATION ESTABLISHMENTS
Business/ Food Establishment
'bu.-CAI O U.)1 �d W ( I'
b
Contact Person/Title for Grease Traps:y Y I(U )C TCn I I r S-7I V
Name of Company scheduled to pump internal grease trap(s) monthly:
Name of Company scheduled to pump external grease trap quarterly:
Please attach the following documents to this application:
• Most recent waste hauler receipt or waste hauler manifest
• Appropriate permit fee based on new fee schedule (Checks can be made out to the Town of
Mansfield)
Food Establishments Fee
3 grease interceptors/traps or less and/or 1 yellow grease collection $50
container
Each grease interceptor/trap over 3 $50 ($200 max)
I THE UNDERSIGNED HAVE OBTAINED AND REVIEWED THE MANSFIELD BOARD OF HEALTH FATS, OILS, AND
GREASE (FOG) REGULATIONS APPROVED AND ADOPTED ON OCTOBER 4, 2018.
In consideration of thearanting of the permit, the undersigned agrees to the conditions of the permit
and acknowledges that x e information submitted in these documents is true, accurate and complete.
Siened <1 Date
Print N
Facility Operational Information
Please answer all questions in this section. If an item is not applicable, indicate "N/A". Unless otherwise
specified, please print or type.
Seating Capacity (per Fire Department Regulation):
Seating Capacity (Actual Count):
Normal Hours of Food Preparation/Service:
Monday Aw�Iy 1L�FU//,r,
Thursday LY/1— _C I�
Sunday ( - ( M
2kf�b
°iD � �.No("16-t 14
Tuesday ii1 — Wednesday
Friday 1 — I &/1 Saturday
I SCUM- 9—a t
Please indicate the NUMBER of kitchen fixtures used in your establishment and if it is attached to a Grease
Removal Units (GRU/trap)
Number in
establishment
Attached to
GRU
3 compartment sink
®
Handwashing sink
Commercial Dishwasher
Bar sink
Mop Sink
Garbage Disposal
Ice Making Machines
'1
Fryolators
Grills or Ovens
Exhaust Hoods
Floor drains
Other:
How are hood vents cleaned? (i.e., in three (3) bay sink, off site by private company):
Is dinnerware pre -rinsed before being washed? x Yes
If yes, at what station/sink? Dk I , Si h V�
No
Grease Trans and Grease Removal
Internal Grease Traps
How many indoor Grease Removal Units (GRU/trap) are on site?
Please list fixtures attached to eachgrease trap
Grease Trap 1
Grease Trap 2
Grease Trap 3
Grease Trap 4
Grease Trap 5
External Grease Traps
Does this establishment have an outdoor Grease Removal Unit (GRU/Interceptor)?
& Yes
No Size
Where is the existing outdoor GRU located? Oaf back
lions
If the owner is responsible for external trap pumping, provide the Name, Address and Telephone Number of
the property owner below:
Property Owner's Name:
Property Owner's Address:
Property Owner's Telephone Number:
Yellow Grease Waste
Do you store yellow grease waste from fryolators?
Where is the grease storage unit located?
How often is this grease storage unit emptied?_
Please list the vendor who removes the wa
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
U11 www.ntass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Business/Organization Name:
I
PA
Address: (.—I/-1p,`,, �,�,--�` !, -,x, % `11 r �-`A t � +� •-� `
City/State/Zip.' sl1�V 1 dd k* Phone #: %(--t) �
Are on an employer? Check the appropriate box: Business Type (required):
_ 5. ❑Retail
I. I am a employer with Z employees (full and/
or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment
2. ❑ I am a sole proprietor or partnership and have no 7, ❑ Office and/or Sales (incl. real estate, auto, etc.)
employees working for me in any capacity. g, ❑ Non-profit
[No workers' comp. insurance required]
3.0 We are a corporation and its officers have exercised 9. ❑Entertainment
their right of exemption per c. 152, § 1(4), and we have 10.❑ Manufacturing
no employees. [No workers' comp. insurance required]* I I .❑ Health Care
4. ❑ We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp. insurance req.] 12.❑ Other
Any applicant that checks box # I must also fill out the section below showing their workers' compensation policy information.
**If the corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an
organization should check box #1.
I rtra an employer that is providing workers' contpensatioii insurrr»ce for ray enr plo gees. Belryu is he policy information.
Insurance
Insurer's Address:
City/State/Zip:��n
Policy # or Self -ins. Lie. # V �t 1.tL l.lJ�2 :!�w I Expiration Date: OW f 2ct 11-3-03L-i
Attach a copy of the workers' compensation policy declaration page (slowing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations-ofthe Dlk-f[Lbi insurance coverage verification.
I do Itereby certify, ander pains aytrl penalties of perjury that the information provided above is trite and correct.
�—t Date tL �Gc3( 2i!
Sitznattne
Fr�
e only. Do not write in this area, to be completed by city or town official.
own: Permit/License #
thority (circle ore):f Health 2. Building Department 3. City/Town Cleric 4. Licensing Board 5. Selectmen's Office
erson: Phone #:
>.6. , .,.
z
O
LLM
u
'CO
Vl
O
LU
0/
I0,
O
MCI
0
� - N
� O
O X
w
w
U
V
z
I--�I
z
40
z
W4
Q�
!4
w
ki
U
O
N
w
r
N
N
W
M
N
N
w
o
a
a)
o
A
U
w
o
U
z
�
Q
U
q
0
ti
N � ptlj
� O
h
o :7 N
tl
�
y
0
LLM
W
V
W
z
Q
2
c
O
0
ICI
w
O
w
`.
z
h�l
z
W
z
w
P4
N
7
z
rw�
V
w
1—�
=
O
N
W
�
N
M
�
M
a
Cd
Fz �
oho
zLd¢
0
�
w
U
ti
w
d
a
� e
w
ES
6V
PROMETRIC
VINCENZO BOLLELLA
Who has met all the
professional requirements for certification in
food service safety and santalion.
anrs�
F A6i10�110 u04uY
::4WUYYwY9rwbWtiew
WrW�abIYlWbWelr
1.
Exam 6601 Recognized By Conference For Food Protection
Certificate No: 2080176
Exam Date: 12J02119
Test Code: 6203046601
Ryan McMillian. Client Servlces Manager Expires on: 12/02/24
Promeltic 1 7941 Ca rale Dtive, NOBingh... MO 21236 I 806.B24 2736
— — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — 6 c- Cat I k r e — —
VINCENZO BOLLELLA
101 CLAY STREET
CENTRAL FALLS, RI 02863
Tgl Fridays Massachesetts- Savage
Prometric
Score Report
Congratulations You passed the Certified
Professional Food Manager examination.
Your Score is as follows:
Score Status Exam Date
83 PASS 1210212019
— — — — — — — — — — — — — — — — — — —
I
I PROM ETRIC c. .. :,. ,r .,:.• I®� 1
I
VINCENZO BOLLELLA
FOP MANAGERCERTIF
I Baam6601�ecogn¢ed By Conference For oar) FroteoUon 1
1 009369847 12102119 1
1 ION Date
2080176 E� 12/02/24 1
1 Can x Dpres on
` — — — — — — — — — — — — — — — — —
Cut Item
Scanned with CamScanner
w
O
w
w
U
V
z
7�
-i
_ J
w
z
4
3
z
w
w
a
�•
w
J
m
O
°
ry
W
N
U
N
N
Z
o
U
w
u
z
t
40Q
U
q
Q
"ZO N o
Q�Q N a zQ� u
v
O�� w 4
ZC4¢ I
0
w
v
d
�
vivo
N
ad�w
A
tl C' 4
Y
C
O T7 fi
ti
y
a